Healthcare Provider Details

I. General information

NPI: 1184679375
Provider Name (Legal Business Name): SAMUEL FITZSIMONS RAVENEL II MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6671 CAROLINE ST
MILTON FL
32570-4781
US

IV. Provider business mailing address

2315 W JACKSON ST
PENSACOLA FL
32505-7552
US

V. Phone/Fax

Practice location:
  • Phone: 850-981-9433
  • Fax: 850-981-9436
Mailing address:
  • Phone: 850-436-4630
  • Fax: 850-436-2095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberME128058
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: